Upper eyelid rotation flap for reconstruction of medial canthal by nyut545e2


									       Upper eyelid rotation flap for reconstruction of
                   medial canthal defects
                         Daniel S. Behroozan, MD,a and Leonard H. Goldberg, MD, FRCPa,b
                                                Houston, Texas

M          edial canthal defects resulting from cancer            canthal defects using a superiorly based eyelid rota-
           resection after Mohs micrographic surgery              tion flap from a contiguous cosmetic subunit with
           present challenging reconstruction dilem-              skin of identical color, texture, and thickness.
mas. In fact, medial canthal reconstruction has been
controversial because of the time-honored method
                                                                  OPERATIVE TECHNIQUE
of second-intention healing in wound management
                                                                      Key features that must be identified before exe-
of this area.1 Yet, small flaps and grafts for repair of
                                                                  cution of this repair technique include size, depth,
cutaneous medial canthal defects may result in a
                                                                  and location of the defect, and whether the lacrimal
quicker healing process with excellent cosmetic re-
                                                                  duct system has been damaged by tumor excision.
sults. The main difficulties of reconstruction of the
                                                                  Indications for upper eyelid rotation are similar to
medial canthal region are the lack of local availability
                                                                  those indicated for consideration of second-inten-
of similar thin eyelid skin, and the concavity of the
                                                                  tion healing; namely, lesions less than 1.5 cm that do
defect to be repaired.
                                                                  not involve the upper eyelid.4 Laxity of the upper
    The area of the medial canthus includes the free
                                                                  eyelid skin is the essential component for rotating
tissue margins of the upper and lower eyelids, the
                                                                  tissue from the upper eyelid into the recipient defect
bony attachments of the medial canthal tendon, the
                                                                  site. The flap is considered practical for patients with
lacrimal puncta, and arteriovenous and neural bun-
                                                                  superficial to moderately deep wounds that do not
dles that supply and innervate the region. The
                                                                  sacrifice the lacrimal apparatus.
literature describes a multitude of surgically complex
                                                                      The procedure is performed under local anesthe-
and intricate reconstruction methods including eye-
                                                                  sia. The defect at the medial canthal region is
lid myocutaneous transposition flaps, glabellar flaps,
                                                                  measured and a flap of adequate size is marked at
cheek flaps, V-Y advancement flaps, and skin grafts
                                                                  the lower margin of the eyebrow on the adjacent
for repair of defects of the medial canthus.2-6
                                                                  upper eyelid (Figs 1 and 2). The flap to defect size
Although these reconstructive options represent
                                                                  ratio should be 3:1 to 4:1 to ensure adequate blood
tested and widely used choices for medial canthal
                                                                  supply across the flap. An incision is then made
restoration, they are limited in that these techniques
                                                                  through the skin into the subcutaneous tissue of the
often provide a less than ideal color or texture
                                                                  upper eyelid below the eyebrow to facilitate move-
match, provide tissue that is either too thick or too
                                                                  ment of the flap into the recipient site (Fig 3). The
thin, or place incisions that cross aesthetic units and
                                                                  flap is undermined and elevated, with the fulcrum
                                                                  for rotation at the medial canthal tendon, and rotated
    We describe a novel flap that is conceptually
                                                                  medially into the defect. A skin hook may facilitate
simple to design and execute for the repair of medial
                                                                  proper placement of the flap and determines if there
                                                                  is enough donor skin to fill the defect (Fig 4).
                                                                  Subcutaneous layers of absorbable sutures are usu-
From DermSurgery Associatesa and the Department of Medicine       ally not necessary as there is no tension on the flap.
   (Dermatology), University of Texas, MD Anderson Cancer         The flap is sutured using cutaneous 6-0 nonabsorb-
Funding sources: None.                                            able sutures in either an interrupted or running
Conflicts of interest: None identified.                           fashion. The secondary defect below the eyebrow
Reprint requests: Leonard H. Goldberg, MD, FRCP, DermSurgery      is closed by lifting the eyelid skin to its new position
   Associates, 7515 Main, Suite 240, Houston, TX 77030. E-mail:   at the lower border of the eyebrow (Fig 5). When
                                                                  rotating upper eyelid skin, a dog-ear is taken across
J Am Acad Dermatol 2005;53:635-8.
                                                                  the bridge of the nose within relaxed skin tension
ª 2005 by the American Academy of Dermatology, Inc.               lines. This dog-ear may be avoided by using the
doi:10.1016/j.jaad.2005.03.024                                    halving technique of suturing two sides of unequal

636 Behroozan and Goldberg                                                                    J AM ACAD DERMATOL
                                                                                                      OCTOBER 2005

             Fig 1. Medial canthal defect.                          Fig 3. Rotation of flap into donor site.

Fig 2. Skin marking delineating the planned eyelid rota-   Fig 4. Use of skin hook to ensure adequate donor tissue
tion flap.                                                  for rotation.

length. Finally, a bolster dressing may be used to         lack of similar skin in the vicinity. As a result, second-
hold the flap down securely into the concave sur-          intention healing is often used as a default. The flap
face. The 1-week (Fig 6) and 4-week (Fig 7) follow-        we describe presents a simple and relatively easy
up results are shown.                                      option for repair of superficial to moderately deep
                                                           defects that do not compromise the lacrimal appa-
DISCUSSION                                                 ratus. Donor skin for medial canthal repairs includes
   The medial canthus is an area that has been a           the glabella and the adjacent upper aspect of the
historically challenging location for postoperative        cheek; however, both of these donor sites provide
repair because of the concavity of the area and the        skin that is thicker than that of the medial canthal
J AM ACAD DERMATOL                                                                  Behroozan and Goldberg 637

Fig 5. Closure of secondary defect by lifting eyelid skin to
its new position at the lower border of the eyebrow.

                                                                         Fig 7. Four week follow-up results.

                                                                  A full-thickness skin graft is an option that is
                                                               useful for larger defects and especially in younger
                                                               patients with superficial defects whose lack of upper
                                                               eyelid skin laxity precludes the use of rotation flaps
           Fig 6. One week follow-up results.                  as a reparative choice. Skin may be harvested from
                                                               the retroauricular, supraclavicular, or often the op-
                                                               posite upper eyelid. Disadvantages of full-thickness
region. Given the laxity of upper eyelid skin in well          grafting includes the need for a donor site resulting in
selected patients described above and the vascularity          a secondary wound, possibilities of poor graft take,
of eyelid skin, the upper eyelid rotation flap is an            poor color and texture match at the recipient site,
excellent option for medial canthal repair with little         and the need for a bulky and prolonged bolster
or no tension.                                                 dressing for at least 1 week.
    Second-intention healing is a time-honored                    The use of flaps, the most popular of which have
method of healing that is especially useful for older          historically been from the glabellar region, offer
patients with loose skin. Contracture and healing of           good color and texture match to the medial canthal
defects is often expected in 4 to 6 weeks and results          area. Yet, this flap is limited by that fact that it is
are often excellent with lack of postoperative pain            inherently thicker skin from a second cosmetic unit
and infections. Further advantages of this technique           that is often bulky and distorts the naturally concave
are in its simplicity and lack of need for further             shape of the medial canthus. In addition, secondary
surgical manipulation of tissue for reparative needs           debulking and pedicle takedown procedures are
especially in a growingly elderly population with              often needed.
cutaneous neoplasms. Disadvantages include length                 The upper eyelid rotation flap described above
of time for complete healing and need for meticulous           does have limitations in that defects that are partic-
wound care and bulky bandages for a prolonged                  ularly large or deep may not be amenable to this
period that is often frustrating for patients. In addi-        reparative technique. Canthal webbing may result if
tion, healing may lead to pulling of the lid anteriorly        there is not enough upper eyelid donor skin for
off the globe as a result of wound contraction leading         rotation into a defect at hand. Rotation puckers may
to ectropion formation, an elevation of the canthus to         appear toward the caruncle and may be routinely
a higher position as a result of scar formation, or            excised during reconstructive repair. However, be-
both. These complications may result in the need for           cause of the thin and loose skin present at the inner
a second reconstructive procedure at a later date for          canthus, the authors have found that puckers are
surgical correction.                                           very forgiving and often stretch out on their own in
638 Behroozan and Goldberg                                                                         J AM ACAD DERMATOL
                                                                                                            OCTOBER 2005

this region. In addition, the medial canthus is a          thickness. Evaluation of defect and upper eyelid
concave surface, and the flap should have a bolster         laxity will determine if this flap is feasible in a
dressing applied for 1 week to hold the flap in place,      selected patient, and may provide the dermatologic
which may be disconcerting to some patients.               surgeon with an option other than prolonged sec-
Basting sutures are not routinely placed as the bolster    ond-intention healing, grafting, or more intricate
dressing stays in place for 1 week by which time the       flaps leading to rapid and outstanding results for
base of the flap has firmly adhered to the underlying        his/her patients.
tissue. Nonetheless, it would not be incorrect to
place basting sutures if the surgeon thought they
would be of benefit in a particular case. Yet, the          REFERENCES
upper eyelid rotation flap is from the same cosmetic        1. Lowry JC, Bartley GB, Garrity JA. The role of second-intention
subunit as the defect for medial canthal reconstruc-          healing in periocular reconstruction. Ophthal Plast Reconstr
tion; thus, it has the same skin texture, color, and          Surg 1997;13:174-88.
thickness as the original defect, resulting in excellent   2. Jelks GW, Glat PM, Jelks EB, Longaker MT. Medial canthal
                                                              reconstruction using a medially based upper eyelid myocuta-
cosmetic outcomes. Patients must be individually              neous flap. Plast Reconstr Surg 2002;110:1636-43.
evaluated and selected to ensure that there is ade-        3. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic
quate excess eyelid skin to optimize healing and              approach. Plast Reconstr Surg 1993;91:1017-24.
anatomic restoration of the medial canthus.                4. Moy RL, Ashjian A. Periorbital reconstruction. J Dermatol Surg
    In summary, we believe that the upper eyelid              Oncol 1991;17:153-9.
                                                           5. Anderson RL, Edwards JJ. Reconstruction by myocutaneous
rotation flap is a reliable, technically practical, and        eyelid flaps. Arch Ophthalmol 1979;97:2358-62.
aesthetic method for medial canthal repair that            6. Rodriguez RL, Zide BM. Reconstruction of the medial canthus.
provides superb color, texture match, and tissue              Clin Plast Surg 1988;15:255.

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